Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a strategy for postpartum haemorrhage management: A narrative review.

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide, with a significant impact on global health. Optimal management of PPH involves distinct steps executed simultaneously by a multidisciplinary approach, with anesthesiologists playing a key role in hemodynamic control and patient resuscitation. In this context, an aortic blood flow interruption through an internal balloon should be considered a rescue option among the various opportunities, to treat or prevent abdominal hemorrhages. Given this perspective, there is increasing interest in the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), originally used in trauma and military medicine, which has emerged as a novel strategy for managing PPH. Indeed, this technique has shown promise in managing severe cases of PPH, especially where traditional measures are insufficient. It also offers potential as a prophylactic measure in pregnancies with high risk for PPH, such as in the case of placenta accrete spectrum. This review aims to examine the efficacy, safety, and potential applications of REBOA in PPH management and prevention. At the same time, challenges such as the need for skilled operators, potential complications, costs, and the consideration of fetal safety were also discussed. REBOA presents as a promising tool against PPH, with efficacy in reducing blood loss, preserving fertility, and potentially decreasing maternal mortality and improving outcomes. However, its implementation requires careful consideration, training, and further research to establish clear guidelines for its use in obstetric care.

Impact of the Early COVID-19 Pandemic on the Quality of Obstetric Care in a Tertiary Care Center in Karachi, Pakistan.

Objective This study aimed to assess the indirect impact of the COVID-19 pandemic on obstetric quality measures. Materials and methods This cross-sectional study was conducted at a private-sector tertiary care hospital in Karachi, Pakistan. Data were collected for specific antenatal, intrapartum, and postpartum care indicators during the initial six months of the COVID-19 phase (March to August 2020) and compared with baseline measures from the preceding six months before the COVID-19 phase (September 2019 to February 2020) using frequencies and percentages. Results During COVID-19, there was a 10% reduction (pre-COVID: 1041 and during COVID: 946) in outpatient obstetric volumes and a 65% increase (pre-COVID: 240 and during COVID: 396) in clinic cancellations, indicating a decreased influx of antenatal patients. Teleclinics served 8.3% (1429/18279) of the total obstetric patients during this period. Marginal decreases were observed in spontaneous vaginal deliveries 1358 (44%) vs 1049 (42.4%) and labor induction rates 818 (26.6%) vs 606 (24.2%). Additionally, there was a slight increase in instrumental deliveries, 121 (3.9%) vs 114 (4.6%) during the COVID phase. However, these changes were not statistically significant. Similarly, no substantial impact was observed on elective and emergency C-sections. Notably, there were more cases of primary postpartum hemorrhage (PPH) during the COVID-19 phase 36 (1.17%) vs 46 (1.86%), and these changes were statistically significant (p= 0.035). Similar trends were observed for eclampsia (p =0.05) and preeclampsia cases (p-value 0.074). However, other maternal morbidity indicators and intrauterine fetal deaths remained relatively unchanged. NICU admissions increased significantly (p=0.001), while early neonatal deaths remained unaffected. Patient satisfaction rates remained steady for inpatients and improved for outpatients during COVID-19. Conclusion The COVID-19 pandemic primarily affected antenatal volumes, neonatal admissions, and maternal morbidity indicators such as PPH, preeclampsia, and eclampsia. Despite the challenges, patient satisfaction and quality care standards were maintained during COVID-19 through new strategies and revised patient care processes.

Uterine Artery Embolization: A Case Report on Primary Postpartum Hemorrhage Management.

When traditional therapies fail to control obstetric emergencies such as postpartum hemorrhage (PPH), uterine artery embolization (UAE) has become an essential intervention. This case study demonstrates the effective use of UAE in a 32-year-old patient who had an elective cesarean section and was experiencing refractory PPH. Despite initial attempts at controlling bleeding with uterotonic agents and surgical intervention, the hemorrhage persisted, necessitating packed red blood cell transfusion. A multidisciplinary team opted for UAE due to the patient's deteriorating condition. Gelatin sponge particles were utilized as embolic agents, resulting in the immediate cessation of uterine blood flow and the stabilization of the patient. This case underscores the importance of early detection, collaborative decision-making, and prompt intervention in managing PPH. UAE offers several advantages, including targeted vascular occlusion, rapid bleeding control, and the preservation of fertility. Further research and practice are warranted to optimize UAE techniques and enhance outcomes in obstetric emergencies. The primary cause of severe maternal morbidity and death is postpartum hemorrhage. For successful uterine artery embolization (UAE), prompt management is essential. UAE is widely acknowledged as a dependable and safe process.

Educational results of the Japan Maternal Emergency Life-Saving (J-MELS) simulation training organized by Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS): a 12-month longitudinal follow-up study in Japan.

AIMS: This study aimed to evaluate the long-term results of Japan Maternal Emergency Life-Saving (J-MELS) simulation training on obstetric healthcare providers, over a 12-month follow-up period. METHODS: A total of 273 trainees from 17 J-MELS Basic courses conducted between August 2021 and October 2023 were included. The trainees' responses to the pre- and post-tests, questionnaires, and self-reports on the usefulness of the J-MELS scenarios in actual clinical settings at 1, 6, and 12 months after the training were analyzed. Multivariate logistic regression analysis was also conducted to identify the factors influencing knowledge retention. RESULTS: We found an overall improvement in clinical knowledge acquisition after J-MELS training and a significant retention of this improvement at least until 12 months later. However, these scores gradually declined over. Trainees reported increased usefulness of J-MELS scenarios in actual clinical practice at 1, 6, and 12 months after training, particularly in managing obstetric emergencies such as atonic postpartum hemorrhage. Knowledge retention was influenced by several specific factors, such as years of clinical experience, affiliated institutions, qualifications, and especially pre-test scores. CONCLUSION: Our longitudinal follow-up study demonstrated, for the first time, the long-term results of J-MELS simulation training using post-tests and self-report data. Our findings provide valuable insight into the impact of J-MELS simulation training on maternal emergency care. By elucidating the factors influencing knowledge retention and practical utility, the findings offer actionable recommendations for optimizing training strategies and improving maternal outcomes in actual clinical practice.

Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management.

Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.

Conservative approaches to postpartum haemorrhage.

Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.

Short and long-term menstrual, reproductive, and mental health outcomes after the intrauterine use of chitosan tamponade or the Bakri balloon for severe postpartum hemorrhage: an observational study.

OBJECTIVE: This retrospective follow-up study analyzes the effect of intrauterine postpartum hemorrhage (PPH) therapy on menstrual, reproductive, and mental health outcomes. METHODS: All women who delivered at a university hospital between 2016 and 2021 with PPH and who needed intrauterine therapy were included. A questionnaire on well-being, menses, fertility, and reproductive outcomes was mailed to the patients. Those who did not reply were surveyed by telephone. RESULTS: A total of 214 women treated with chitosan-covered gauze (group A) and 46 women treated with a balloon tamponade (group B) were recruited, and their short-term courses were analyzed. For long-term follow-up, 71 women of group A (33%) and 21 women of group B (46%) could be reached. A total of 89% of group A and 95% of group B had regular menstrual bleeding in the most recent 12 months; 27% (group A) and 29% (group B) were trying to conceive again, and all of them did so successfully. There were 12 deliveries, 3 ongoing pregnancies, 3 miscarriages, and 2 terminations of pregnancies (TOP) in group A and 4 deliveries, 1 miscarriage, and 2 TOPs in group B. More than half of our study participants was sorted into grade II or III of the Impact of Events Scale, indicating they experienced clinical impacts in the form of psychological sequelae. One-quarter of patients had symptoms of post-traumatic stress disorder. CONCLUSION: Chitosan gauze as well as balloon tamponade appear to have few adverse effects on subsequent menstrual and reproductive function. Women after PPH are at increased risk of long-term adverse psychological outcomes.

Prevalence and determinants of moderate-to-severe anaemia in the third trimester of pregnancy: a multicenter cross-sectional study in Lagos, Nigeria.

The high burden of anaemia during pregnancy underscores the urgent need to gain a comprehensive understanding of the factors contributing to its widespread occurrence. Our study assessed the prevalence and the trends of moderate-to-severe anaemia (MSA) in late pregnancy (28 to 36 weeks) and then investigated the key determinants driving this prevalence among women in Lagos, Nigeria. We conducted a secondary data analysis involving 1216 women enrolled in the Predict-PPH study between January and March 2023. We employed a multivariate binary logistic regression model with a backward stepwise selection approach to identify significant predictors of MSA. The study revealed a 14.5% prevalence of MSA during pregnancy. Independent predictors of MSA included having given birth to two or more children (adjusted odds ratio = 1.46, 95% confidence interval: 1.03-2.07), having a maternal body mass index (BMI) of 28 kg/m2 or higher (adjusted odds ratio = 1.84, 95% confidence interval: 1.29-2.61), having less than tertiary education (adjusted odds ratio = 1.51, 95% confidence interval: 1.08-2.11), and being unemployed (adjusted odds ratio = 1.97, 95% confidence interval: 1.19-3.26). It is crucial for pregnant women, particularly those with higher parities and elevated BMI, to be monitored regularly for anaemia and its consequences during their antenatal care. Additionally, addressing the link between low education, unemployment, and anaemia necessitates comprehensive strategies that empower women in terms of education and economic status to enhance the overall well-being of individuals and communities, ultimately reducing the prevalence of anaemia and associated health issues in pregnancy.

Prenatal anaemia and risk of postpartum haemorrhage: a cohort analysis of data from the Predict-PPH study.

BACKGROUND: Most previous clinical studies investigating the connection between prenatal anaemia and postpartum haemorrhage (PPH) have reported conflicting results. OBJECTIVES: We examined the association between maternal prenatal anaemia and the risk of PPH in a large cohort of healthy pregnant women in five health institutions in Lagos, Southwest Nigeria. METHODS: This was a prospective cohort analysis of data from the Predict-PPH study that was conducted between January and June 2023. The study enrolled n = 1222 healthy pregnant women giving birth in five hospitals in Lagos, Nigeria. The study outcome, WHO-defined PPH, is postpartum blood loss of at least 500 milliliters. We used a multivariable logistic regression model with a backward stepwise conditional approach to examine the association between prenatal anaemia of increasing severity and PPH while adjusting for confounding factors. RESULTS: Of the 1222 women recruited to the Predict-PPH study between January and June 2023, 1189 (97·3%) had complete outcome data. Up to 570 (46.6%) of the enrolled women had prenatal anaemia while 442 (37.2%) of those with complete follow-up data had WHO-defined PPH. After controlling for potential confounding factors, maternal prenatal anaemia was independently associated with PPH (adjusted odds ratio = 1.37, 95% confidence interval: 1.05-1.79). However, on the elimination of interaction effects of coexisting uterine fibroids and mode of delivery on this association, a sensitivity analysis yielded a lack of significant association between prenatal anaemia and PPH (adjusted odds ratio = 1.27, 95% confidence interval: 0.99-1.64). We also recorded no statistically significant difference in the median postpartum blood loss in women across the different categories of anaemia (P = 0.131). CONCLUSION: Our study revealed that prenatal anaemia was not significantly associated with PPH. These findings challenge the previously held belief of a suspected link between maternal anaemia and PPH. This unique evidence contrary to most previous studies suggests that other factors beyond prenatal anaemia may contribute more significantly to the occurrence of PPH. This highlights the importance of comprehensive assessment and consideration of various maternal health factors in predicting and preventing this life-threatening obstetric complication.

Risk factors and management of perinatal genital hematoma: A single, tertiary medical center retrospective study in China.

OBJECTIVES: The goal of this study was to identify the risk factors associated with puerperal genital hematoma (PGHA) and analyze the management strategies employed and the resulting maternal outcomes. METHODS: This retrospective cohort study examined the pregnant women delivering vaginally with PGHA in Peking University Third Hospital during January 2002 to December 2021. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. Independent-samples t-test was performed for continuous variables. Chi-squared test was performed to compare categorical data. RESULTS: A total of 47 women with PGHA were included, and 94 matched controls were enrolled during the same study period. Compared with the control group, labor induction (34.0% vs. 9.6%, P = 0.000) and episiotomy (66.0% vs. 31.9%, P = 0.000) were more frequently performed in PGHA cases. There was a significantly higher incidence of postpartum hemorrhage (PPH) (53.2% vs. 6.4%, P = 0.000) in PGHA patients than in controls. Compared with the patients with <5 cm hematoma, the proportion of prenatal anemia (25.8% vs. 0.0%, P = 0.027) and the incidence of PPH (67.7% vs. 25.0%, P = 0.005) were significantly higher in patients with ≥5 cm hematoma. In comparison, the active period was significantly shorter (3.1 ± 1.9 vs. 5.1 ± 3.0, P = 0.031) in patients with ≥5 cm hematoma. There were significant differences in perineal pain and swelling (31.3% vs. 67.7%, P = 0.017), vulva hematoma (93.8% vs. 48.4%, P = 0.002) and surgical treatment (62.5% vs. 96.8%, P = 0.002). Nearly half of the patients in the ≥5 cm group underwent secondary suture (41.9% vs. 6.3%, P = 0.011). In patients with PGHA detected after more than 2 h, the body mass index was substantially higher (24.5 ± 4.3 vs. 21.4 ± 2.7, P = 0.011), and the weight gain during pregnancy (14.1 ± 4.3 vs. 11.4 ± 3.5, P = 0.021) was significantly lower. Compared with the patients in PGHA without PPH, age (31.7 ± 4.4 vs. 29.4 ± 2.6, P = 0.033) and newborn birth weight (3367 ± 390 g vs. 3110 ± 419 g, P = 0.045) were considerably higher in PGHA cases with PPH, and the platelet count ([182 ± 44] × 109/L vs. [219 ± 51] × 109/L, P = 0.015) was significantly lower. CONCLUSIONS: Pregnant women who underwent labor induction and episiotomy had a higher incidence of PGHA. The PGHA-related PPH rate is significantly increased. Active surgical treatment is recommended for patients with ≥5 cm hematoma.

Incidence and Antepartum Risk Factors of Severe Postpartum Haemorrhage in Anaemic Pregnant Women in Lagos, Nigeria: A Secondary Cohort Analysis.

BACKGROUND: The magnitude and risk factors for postpartum haemorrhage (PPH) have been extensively investigated, although little is currently known about the incidence and predictors of severe PPH, specifically among women affected by prenatal anaemia in Nigeria. OBJECTIVES: The study determined the incidence and antepartum risk factors of severe PPH in anaemic pregnant women in five health institutions in Lagos, Southwest Nigeria. METHODS: A secondary analysis was performed using the data of pregnant women with anaemia from the "Predict-PPH" study that was conducted between January and June 2023. This study included n=570 pregnant women affected by anaemia who gave birth in five hospitals in the Lagos metropolis of Nigeria. The study outcome was severe PPH, defined as an estimated blood loss of at least 1000 mL within 24 hours of childbirth. A backward stepwise conditional approach in a multivariable logistic regression model was utilised to identify the independent risk factors for severe PPH in anaemic pregnant women. RESULTS: Of the 570 women with prenatal anaemia enrolled in the primary study, 42 (7.4%) had severe PPH. The identified independent risk factors for severe PPH were maternal obesity (adjusted OR = 3.85, 95% CI = 1.85-8.02), antepartum haemorrhage in index pregnancy (adjusted OR = 2.98, 95% CI = 1.29-6.90), uterine fibroids (adjusted OR = 6.10, 95% CI = 2.39-15.52), delivery gestational age ≥39 weeks (adjusted OR = 2.62, 95% CI = 1.23-5.56), and delivery by caesarean birth (adjusted OR = 16.75, 95% CI = 5.81-48.31). CONCLUSION: About one in 13 anaemic pregnant women enrolled in the study developed severe PPH during childbirth. Maternal obesity, antepartum bleeding in the current pregnancy, co-existing uterine fibroids in pregnancy, delivery gestational age beyond 38 weeks, and caesarean birth in the current pregnancy were factors that were significantly associated with severe PPH in anaemic pregnant women. These findings underscore the importance of increased vigilance during both the antenatal and peripartum periods to identify women with these risk factors for the initiation of timely interventions to prevent severe PPH.

Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices - A budget impact analysis of the Jada® System in the German obstetrics setting.

OBJECTIVE: This study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). STUDY DESIGN: Evidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A "downgrading mechanism" was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. RESULTS: Data from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1-4, respectively, CONCLUSION: This is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.

Comparison of Two Viscoelastic Testing Devices in a Parturient Population.

Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland-Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.

Machine learning approach to predict postpancreatectomy hemorrhage following pancreaticoduodenectomy: a retrospective study.

BACKGROUND: Postpancreatectomy hemorrhage (PPH) is a rare yet dreaded complication following pancreaticoduodenectomy (PD). This retrospective study aimed to explore a machine learning (ML) model for predicting PPH in PD patients. METHODS: A total of 284 patients who underwent open PD at our institute were included in the analysis. To address the issue of imbalanced data, the adaptive synthetic sampling (ADASYN) technique was employed. The best-performing ML model was selected using the PyCaret library in Python and evaluated based on recall, precision, and F1 score metrics. In addition to assessing the model's performance on the test data, bootstrap validation (n = 1000) with the original dataset was conducted. RESULTS: PPH occurred in 11 patients (3.9%), with a median onset time of 22 days postoperatively. These minority cases were oversampled to 85 using ADASYN. The extra trees classifier demonstrated superior performance with recall, precision, and F1 score of 0.967, 0.914, and 0.937, respectively. Both validation using the test data and bootstrap resampling consistently demonstrated recall, precision, and F1 score exceeding 0.9. The model identified the peak value of C-reactive protein during the first 7 postoperative days as the most significant feature, followed by the preoperative neutrophil-to-lymphocyte ratio. CONCLUSIONS: This study highlights the potential of the ML approach to predict PPH occurrence following PD. Vigilance and early interventions guided by such model predictions could positively impact outcomes for high-risk patients.

Controlled Sequential Doping of Metal Nanocluster.

Atomically precise doping of metal nanoclusters provides excellent opportunities not only for subtly tailoring their properties but also for in-depth understanding of composition (structure)-property correlation of metal nanoclusters and has attracted increasing interest partly due to its significance for fundamental research and practical applications. Although single and multiple metal atom doping of metal nanoclusters (NCs) has been achieved, sequential single-to-multiple metal atom doping is still a big challenge and has not yet been reported. Herein, by introducing a second ligand, a novel multistep synthesis method was developed, controlled sequential single-to-multiple metal atom doping was successfully achieved for the first time, and three doped NCs Au25Cd1(p-MBT)17(PPh3)2, Au18Cd2(p-MBT)14(PPh3)2, and [Au19Cd3(p-MBT)18]- (p-MBTH: para-methylbenzenethiol) were obtained, including two novel NCs that were precisely characterized via mass spectrometry, single-crystal X-ray crystallography, and so forth. Furthermore, sequential doping-induced evolutions in the atomic and crystallographic structures and optical and catalytic properties of NCs were revealed.

A rare case of morbidly adherent placenta in a young Primigravida with RH negative pregnancy managed with peripartum subtotal hysterectomy.

INTRODUCTION AND IMPORTANCE: Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause of maternal mortality rate. Prevention and early intervention can prevent this complication of delivery. However condition like placenta accreta leads to retention of placenta and makes PPH inevitable. CASE SUMMARY: We present the case of massive postpartum hemorrhage secondary to Placenta accreta in young primigravida with RH negative pregnancy. Clinical findings and investigations were not significant during her admission. She delivered the baby via vaginal route but placenta was not expelled till 30 min. Due to failed manual removal of placenta patient was shifted to OT.Manual vacuum aspiration was done in OT setting and chunks of placenta along with blood clots were obtained.Uterine balloon tamponade was inserted. Due to persistent PV bleeding subtotal hysterectomy was carried out in line for placenta accreta. DISCUSSION: Placenta accreta being one of the life threatening obstetric condition, it should be diagnosed as early as possible and need prompt management so as to prevent maternal mortality. Due to increasing number of cesarean delivery the cases of placenta accreta has been rising but rarely in some cases can it present in young primigravida with Rh negative pregnancy. CONCLUSION: In the cases of morbidly adherent placenta it is necessary for obstetrician to early identify such conditions and timely intervene to save the mother's life. Moreover Rh negative could be a hidden risk factor.

Triphenylphosphine Derivatives of Allylbenzenes Express Antitumor and Adjuvant Activity When Solubilized with Cyclodextrin-Based Formulations.

Allylbenzenes (apiol, dillapiol, myristicin and allyltetramethoxybenzene) are individual components of plant essential oils that demonstrate antitumor activity and can enhance the antitumor activity of cytotoxic drugs, such as paclitaxel, doxorubicin, cisplatin, etc. Triphenylphosphine (PPh3) derivatives of allylbenzenes are two to three orders of magnitude more potent than original allylbenzenes in terms of IC50. The inhibition of efflux pumps has been reported for allylbenzenes, and the PPh3 moiety is deemed to be responsible for preferential mitochondrial accumulation and the depolarization of mitochondrial membranes. However, due to poor solubility, the practical use of these substances has never been an option. Here, we show that this problem can be solved by using a complex formation with cyclodextrin (CD-based molecular containers) and polyanionic heparin, stabilizing the positive charge of the PPh3 cation. Such containers can solubilize both allylbenzenes and their PPh3 derivatives up to 0.4 mM concentration. Furthermore, we have observed that solubilized PPh3 derivatives indeed work as adjuvants, increasing the antitumor activity of paclitaxel against adenocarcinomic human alveolar basal epithelial cells (A549) by an order of magnitude (in terms of IC50) in addition to being quite powerful cytostatics themselves (IC50 in the range 1-10 µM). Even more importantly, CD-solubilized PPh3 derivatives show pronounced selectivity, being highly toxic for the A549 tumor cell line and minimally toxic for HEK293T non-tumor cells, red blood cells and sea urchin embryos. Indeed, in many cancers, the mitochondrial membrane is more prone to depolarization compared to normal cells, which probably explains the observed selectivity of our compounds, since PPh3 derivatives are known to act as mitochondria-targeting agents. According to the MTT test, 100 µM solution of PPh3 derivatives of allylbenzenes causes the death of up to 85% of A549 cancer cells, while for HEK293T non-cancer cells, only 15-20% of the cells died. The hemolytic index of the studied substances did not exceed 1%, and the thrombogenicity index was < 1.5%. Thus, this study outlines the experimental foundation for developing combined cytostatic medications, where effectiveness and selectivity are achieved through decreased concentration of the primary ingredient and the inclusion of adjuvants, which are safe or practically harmless substances.

Anesthetic Management for Cesarean Delivery in a Patient With a Difficult Airway and Risks for Postpartum Hemorrhage: A Case Report.

Neuraxial anesthesia is the preferred anesthesia technique for cesarean delivery, however, conversion to general anesthesia may be required for a variety of clinical scenarios, including massive post-partum hemorrhage. Obstetric patients are known to have otherwise more difficult airways and emergent situations can increase the likelihood of failed intubation with potentially disastrous consequences. We describe a novel anesthesia technique for cesarean delivery using neuraxial anesthesia as the primary anesthetic technique and electively securing the airway for a patient with multiple risk factors for post-partum hemorrhage and features concerning difficult intubation.

Preeclampsia complicated with hypofibrinogenemia: 2 case reports and review of the literature.

BACKGROUND: Preeclampsia complicated with hypofibrinogenemia is a rare disorder. We report two cases of severe preeclampsia complicated with hypofibrinogenemia followed by postpartum haemorrhage (PPH). CASE: Two women diagnosed as preeclampsia and hypofibrinogenemia developed severe PPH after undergoing Cesarean sections. Besides supplement with fibrinogen concentrate and supportive treatment, the second patient got administration of heparin after delivery and bleeding was stopped. The haemorrhage in case 1 didn't disappear until an hysterectomy. The two patients both recovered and were discharged soon. CONCLUSIONS: Severe preeclampsia patients with hypofibrinogenemia could suffer PPH. It's necessary to detect and master coagulation function. Heparin could be considered to balance hypercoagulation and hypocoagulation to avoid catastrophic haemorrhage and hysterectomy.